Notice to Texas Physicians and Eye Care Providers

Envolve Vision of Texas, Inc.
4000 McEwen Rd.
Dallas, TX 75244-5016

As a licensed eye care HMO in the State of Texas, we accept on a continuous basis applications from ophthalmologists,
opto-metrists and opticians in Texas to join our Medicaid, Medicare, commercial, and Health In-surance Marketplace
networks of eye care providers. App-lications can be obtained by written request to the above address,
through the online request form here, or by calling 1-800-531-2818.

Join the Envolve Vision Network

Thank you for your interest in becoming an Envolve Vision provider. The following information is needed to process your request for panel participation. Please complete this form below for our Network Management Department.

Provider First Name: *

Provider Last Name: *

Provider's Title:

Office Contact Name: *

Group Name: *

TIN: *

DOB: *

NPI: *

CAQH #:

Medicaid #:

Medicare #:

Office Address: *

Office State:*

Office City: *

Office Zip+4: *

Office County: *

Office Phone: *

Office Fax: *

Office Email Address: *

Dispense Glasses:

Dispense Contacts:

Do you practice at a retail chain:

Wal-Mart JCPenny Optical Sears Optical

Target Pearle Vision DOC Optics

Lenscrafters Other

Correspondence Address(If different from above)

Address:

State:

City:

Zip+4:

County:

Products you are interested in participation on:

Medicaid MedicareHealth Insurance MarketplaceCommercial Vision Care

How would you like us to contact you in respose to your request?

PhoneEmail

Please provide an email or phone number below:

Upon receipt of your request for participation, a Provider Participation Agreement (PPA) & Fee Schedules will be mailed to your office for your review and execution

Should you have any questions, please contact Network Management at (800) 531-2818, option 4